‘It’s humid, hot, muddy and sometimes cold at night, but it’s exactly this which makes the beautiful elements of the jungle just that bit more fantastic. Hidden waterfalls, incredible rivers, primary rainforest and then of course the chance of seeing elusive wildlife, jaguars, jaguarondis, monkeys and the plethora of ants, scorpions, spiders and snakes. The Jungle Medicine course is based on the Pacuare River, four hours by raft into the jungle.

The base camp has all the luxuries you don’t expect, with even a raised lecture theatre looking over the river. Expect to work hard in the jungle during the day, getting used to travel and life in the jungle and then relax in comfy chairs listening to a few evening lectures. Towards the end of the week you will have the opportunity to trial your new skills and travel into the jungle, sleeping in hammocks, cooking on fires and navigating through the jungle.

The directing staff will guide you through all of this and allow you to work and learn at your own speed, allowing you to feel safe and gain the most out of your experience and this incredible adventure. This course aims to give you the confidence to look after yourself in the jungle, hence allowing you to focus on the care of a sick patient.

The Jungle Medicine course aims to equip doctors, nurses and paramedics with practical survival skills, an overview of tropical medicine, logistical knowledge and pre-hospital skills required on a jungle expedition.

This action-packed course kicks off by rafting into camp before running through essential information you’ll need for the days ahead.

Splitting the course into practical and theory based elements gives us an opportunity to vary teaching methods and importantly, gets you hands on ‘learning by doing’. You’ll adapt basic navigation and camp craft skills for use in the complex jungle environment, we’ll discuss the common conditions found in jungle environments and learn how to treat this conditions in such a challenging location.

Accreditation will be offered through the Royal College of Surgeons of Edinburgh. We estimate 30 hours of CPD will be awarded for the complete course.

Watch BBC Big Splash tomorrow, 20th June, at 4.30 BBC2 to see Dr Amy Hughes supporting Blue Peters two world records for swimming in one of the deepest stretches of water on the planet.

As often is the case, many of the media operations requiring a medic often do so at the very last minute. This in no way reflects badly on the programme or producers themselves, it is often just the case that many don’t think about the requirement of medical cover for a shoot until highlighted by either the insurance documents or, with final plans in place, the realization of quite how remote the shoot is! The benefits of this for the medic is that it adds a whole new dimension to the event, as limited preparation time only adds to the wonderfully enjoyable challenge of working with the media.

In this case, I had a couple of days to prepare for an overseas shoot with the BBC (Blue Peter). The main challenge for this project arose with the planning of medical kit to take. I needed enough for a 10 strong boat crew, an endurance swim and a country with a scarcely resourced hospital. Once on the boat, the minimal casevac time was thought to be around 24 hours from the time taken to sail from the depths of the pacific ocean to an air strip or helicopter pick up point. And so began my 48 hour almost sleepless venture of composing, ordering and searching for various drugs and bits of kit I may need for any possible medical or traumatic eventuality. In planning it can often be easy to focus on the activity at hand and what injuries could result from that, and overlook the more common likely events that may happen amongst the crew – for example someone slipping on a wet deck and banging their head resulting in a extradural or subdural bleed (time critical) or a myocardial infarction (pretty time critical). Everything needs to be considered, including quantities sufficient to treat one or more individuals who may suffer a similar illness at the furthest possible casevac point – for example a severe bout of food poisoning requiring intravenous fluids and antiemetics 23 hours 59 minutes from aeromedical retrieval! Something to be aware of is that ordering drugs, especially opiates and controlled drugs, takes at least 24 hours and that can be delayed due to stock levels. Also, various forms of signed official paperwork are required prior to online pharmacies dispensing opiates which is time consuming (those who are hospital doctors will find this is the best way to source drugs such as morphine and fentanyl. GPs often have access to a controlled drug prescription pad).

Palau, Latitude 70 30’00″ North, longitude 1340 30’00” east; is an island of approximately 459 square kilometers and with a population of 20000, sitting about 500 miles east of the Philippines forming part of the Micronesian state. The island hosts a beautiful outcrop of rock islands as well as probably the most beautiful coves of sand and gardens of coral. It is a truly stunning island, slowly becoming popular with divers although the dive sites are still relatively untouched.

Palau was to be the island from which Blue Peter presenter Andy Akinwolere started his journey of swimming 8km across one of the worlds deepest trenches. For someone with a fear of deep water and having only learnt to swim ten weeks prior, it was an incredible achievement.

Fortunately the only medical emergency that I was required for was the delivery of an intramuscular injection of Stemetil in a futile attempt to cease the vomiting of a sea sickness victim. The rest of the trip was uneventful and an absolute delight to be part of. In a way though, there is always that slight disappointment that my 26kg of medical kit wasn’t put to use……….!

A middle-aged woman squats motionless on the side of the trail, sheltering her head from the falling snow with a tattered grain sack.

Find out more about Mountain Medicine in Nepal

Luanne Freer, an emergency room doctor from Bozeman, Montana, whose athletic build and energetic demeanor belie her 53 years, sets down her backpack and places her hand on the woman’s shoulder. “Sanche cha?” she asks. Are you OK?

The woman motions to her head, then her belly and points up-valley. Ashish Lohani, a Nepali doctor studying high-altitude medicine, translates.

“She has a terrible headache and is feeling nauseous,” he says. The woman, from the Rai lowlands south of the Khumbu Valley, was herding her yaks on the popular Island Peak (20,305 feet), and had been running ragged for days. Her headache and nausea indicate the onset of Acute Mountain Sickness, a mild form of altitude illness that can progress to High Altitude Cerebral Edema (HACE), a swelling of the brain that can turn deadly if left untreated. After assessing her for HACE by having her walk in a straight line and testing her oxygen saturation levels, the doctors instruct her to continue descending to the nearest town, Namche Bazaar, less than two miles away.

Freer, Lohani and I are trekking through Nepal’s Khumbu Valley, home to several of the world’s highest peaks, including Mount Everest. We are still days from our destination of Mount Everest Base Camp and Everest ER, the medical clinic that Freer established nine years ago, but already Freer’s work has begun. More than once as she has hiked up to the base camp, Freer has encountered a lowland Nepali, such as the Rai woman, on the side of the trail ill from altitude. Thankfully, this yak herder is in better condition than most. A few weeks earlier, just before any of the clinics had opened for the spring season, two porters had succumbed to altitude-related illnesses.

Each year over 30,000 people visit the Khumbu to gaze upon the icy slopes of its famed peaks, traverse its magical rhododendron forests and experience Sherpa hospitality by the warmth of a yak dung stove. Some visitors trek between teahouses, traveling with just a light backpack while a porter carries their overnight belongings. Others are climbers, traveling with a support staff that will aid them as they attempt famous peaks such as Everest (29,029 feet), Lhotse (27,940 feet) and Nuptse (25,790 feet). Many of these climbers, trekkers and even their support staff will fall ill to altitude-induced ailments, such as the famed Khumbu cough, or gastro-intestinal bugs that are compounded by altitude.

A short trip with a group of fellow doctors to the Khumbu in 1999 left Freer desperate for the chance to return to the area and learn more from the local people she had met. So in 2002 Freer volunteered for the Himalayan Rescue Association’s Periche clinic—a remote stone outpost accessed by a five-day hike up to 14,600 feet. Established in 1973, Periche is located at an elevation where, historically, altitude-related problems begin to manifest in travelers who have come up too far too fast.

For three months, Freer worked in Periche treating foreigners, locals and even animals in cases ranging from the simple—blisters and warts—to the serious, instructing another doctor in Kunde, a remote village a day’s walk away, via radio how to perform spinal anesthesia on a woman in labor. Both the woman and the baby survived.

JuniorDr’s Ivor Vanhegan asked Sean about his experience of expedition medicine and advice for junior doctors interested in it as a career.

After training in the UK I decided to work abroad for a while to experience medicine in a more remote environment. It was an early stage in my career but even at this point it was apparent that the broader my knowledge base, the more likely I was to be employed. Expedition Medicine is approximately 60% general practice, 30% environment specific and the remainder trauma. I worked for a year with Raleigh International in Africa, on a ski field in New Zealand and climbed through Central Asia and the Himalayas.

Working as an expedition/wilderness medic I often find myself working alone and without the usual infrastructure we all rely upon on a daily basis. It can sometimes be terrifying and exciting but ultimately extremely satisfying. Furthermore, the skills you develop as an expedition medic are increasingly becoming recognised and valued in other fields of medicine.

Over the last 2 years, I’ve worked in many varied locations and roles throughout the world. This has included: in Antarctica setting up and running one of the remotest clinics in the world, running training courses in Iraq for close protection officers and providing medical cover for production companies in a number of remote locations. I also provided the medical support for a fashion shoot in Southern Africa and have worked as a consultant for the foreign office.

In addition to these roles I have also trained a number of private individuals before they head off on exciting, often solo, expeditions. The future for medics wanting to work in this field is increasingly bright. The specialty is gaining recognition and with that comes remuneration. Soon we may arrive at the stage where medics can choose this as a career pathway rather than a stop gap to a more traditional specialty.

In recognition of this, a postgraduate qualification is now available in Wilderness Medicine. The Fellowship of the Academy of Wilderness Medicine (FAWM) is a postgraduate qualification which recognises experience and learning in the field of Expedition and Wilderness Medicine. It is overseen by the Faculty of Wilderness Medicine in the US.

JuniorDr’s Ivor Vanhegan asked Sean about his experience of expedition medicine and advice for junior doctors interested in it as a career.

After training in the UK I decided to work abroad for a while to experience medicine in a more remote environment. It was an early stage in my career but even at this point it was apparent that the broader my knowledge base, the more likely I was to be employed. Expedition Medicine is approximately 60% general practice, 30% environment specific and the remainder trauma. I worked for a year with Raleigh International in Africa, on a ski field in New Zealand and climbed through Central Asia and the Himalayas.

Working as an expedition/wilderness medic I often find myself working alone and without the usual infrastructure we all rely upon on a daily basis. It can sometimes be terrifying and exciting but ultimately extremely satisfying. Furthermore, the skills you develop as an expedition medic are increasingly becoming recognised and valued in other fields of medicine.

Over the last 2 years, I’ve worked in many varied locations and roles throughout the world. This has included: in Antarctica setting up and running one of the remotest clinics in the world, running training courses in Iraq for close protection officers and providing medical cover for production companies in a number of remote locations. I also provided the medical support for a fashion shoot in Southern Africa and have worked as a consultant for the foreign office.

In addition to these roles I have also trained a number of private individuals before they head off on exciting, often solo, expeditions. The future for medics wanting to work in this field is increasingly bright. The specialty is gaining recognition and with that comes remuneration. Soon we may arrive at the stage where medics can choose this as a career pathway rather than a stop gap to a more traditional specialty.

In recognition of this, a postgraduate qualification is now available in Wilderness Medicine. The Fellowship of the Academy of Wilderness Medicine (FAWM) is a postgraduate qualification which recognises experience and learning in the field of Expedition and Wilderness Medicine. It is overseen by the Faculty of Wilderness Medicine in the US.

The Expedition and Wilderness Medicine course at the Plas y Brenin convenes today. An eclectic mix of delegates and faculty gather today at the National Mountain Centre in North Wales for what promises to be an amazing week. Kicking off the talks are Dr Amy Hughes HEMS medic for Kent Air Ambulance, Steve Jones polar base camp manager for Patriot Hills and now the new Antarctic Camp at Grand Union Glacier and veteran of large scale expeditions to Nicaragua, Chile, Costa Rica, Zimbabwe and Borneo to name but a few and Dr Martin Rhodes medic for Antarctic Logistics operations at the South Pole, resident of the Pyrennes and medic for numerous Bond movies.

The next Expedition and Wilderness Medicine is running in the National Mountain Centre in Plas y Brenin from the 16 – 19 May, contact Catherine at admin@expeditionmedicine.co.uk to secure your place or book online through our lovely website!

We’ve just completed a fantastic week in Keswick enjoying the splendour of the English Lake District in amazing spring sunshine, details of the Extreme Medicine Expo in London are getting firmed up & we’ve news of our Desert Medicine course in Namibia, Diving in the Maldives & our exciting new Antarctic Medical Conference in association with Lindblad Expeditions & National Geographic plus some pretty interesting & eclectic job opportunities.

Mountain Medicine Course Leader Dr Luanne Freer reports from Everest

Desert Medicine Course prepares to gather in Namibia

Dr Nick Knight reflects on the recent Keswick course

Development of the International ‘World Extreme Medicine’ Conference & EXPO – ‘Taking Medicine to the Extremes’

Dr Amy Hughes talks to the camera about Expedition Medicine

Jobs

We hope you enjoy this edition of EWM eNews.

If you haven’t already why not join us on Facebook? We update daily, the latest jobs and course news go up here first and its a great place to meet both like-minded medics and hear about expedition opportunities. So come on and join us.

Mountain Medicine Course Leader Dr Luanne Freer reports from Everest

MOUNTAIN MEDICINE 22.5 CME

Leader of this years Mountain Medicine Course in Nepal Dr Luanne Freer head of the EverestER clinic providing medical cover for Everest climbers & Sherpas alike makes her initial report from Base Camp.Luanne reports; ‘Each year we are amongst the first to arrive at Everest Base Camp for the spring season and we are amongst the last to leave. As we work to set up the EverestER clinic, workers from climbing teams level ground and set up tents in anticipation of the later arrival of the climbers and guides. One of the most important tasks taking place during this time is the planning and setting of the route up the treacherous Khumbu Ice Fall.An elite group of Sherpa climbers, known as the Icefall Doctors, bear the difficult and dangerous task of setting ropes and ladders across the numerous crevasses that make up the ice fall.

Ang Gyeltzen Sherpa is a member of the Icefall Doctors and an electronics wizard. Each year he provides assistance to the clinic. This year, bored because snowfall has delayed work on the icefall route, Ang Gyeltzen helps us set up our new solar charging system.

Desert Medicine Course prepares to gather in Namibia

DESERT MEDICINE 20.5 CME

Our Desert Medicine course departs for Namibia at the end of this month led by Dr Amy Hughes and Dr Christoffer van Tulleken of Channel 4’s ‘Medicine Men Go Wild’ fame.Chris is currently an academic registrar at University College London Hospital in Infectious Disease & Tropical Medicine & has extensive experience of remote medicine. Chris has been the medical consultant and location medic for more than 12 documentary series including BBC’s Tribe, Amazon & Human Planet. He has also presented several documentaries about humanitarianism, science & remote indigenous societies.

The course, set in the shadow of Namibia’s highest peak in a stunningly remote area of Damaraland, covers a whole gamut of desert related subjects including envenomation, desert navigation, tropical medicine & looking for water.

Dr Nick Knight reflects on the recent Keswick course

EXPEDITION MEDICINE CME 23.75

With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills, you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas.

We are very close now to confirming the content, which will be modular in nature & CME certified, the location & the dates. We are able to offer a great discount rate for nurses, paramedics & students & we are hoping to get all this information out to you over the next couple of weeks.Pre register your interest by emailing here

London late April 2012

Salt Lake City September 2012

INTERVIEW WITH MEDICAL DIRECTOR DR AMY HUGHE

FACE 2 FACE

Dr Amy Hughes talks to the camera about Expedition Medicine.As Expedition Medicine’s new medical director Dr Amy Hughes, Pre-hospital Care Registrar with the Kent HEMS Team, speaks about the growing opportunities for medics as Expedition Medicine, a medical sub speciality, continues to grow & develop.This article is in video format & can be watched by following this link

JOBS

EXPEDITION MEDICINE POSTS

If you want to ensure that you hear about the job opportunities as soon as we receive them then we recommend that you ’like’our Facebook group. *URGENT: Doctor required for charity expedition with the Ultimate Travel Company.

Dates: 9-18 June 2011

Location: Kilimanjaro Rongai route

Group size: 35 people from a national charity

Details: You will be in a team with 2 UK Expedition Leaders along with an expert team of local guides. Medical kit, oxygen and hyperbaric chamber provided

Fees: All flights, trek expenses, food included + fee of £400

Outline duties/responsibilities: You will be trekking with the group and will have your own porter to carry the medical kit. You will be expected to provide medical advice, dispense medication and services as appropriate and within your capability to the trek participants and other expedition staff. This may involve triage, stabilization, initial treatment and transfer of anyone suffering a serious illness or injury. You would be expected to have very good communication skills, be an excellent team player and work at all times with the GMC guidelines of Good Medical Practice and the Duties of a Doctor.If you are interested in this post please contact Jennie or Stef at the Ultimate Travel Company with a short resume of your relevant experience email Jennie or Stephanie here or telephone 020 7386 4673.

The Khomas Medical Centre in Windhoek, Namibia, a private multidisciplinary group practice, is looking for qualified doctors to work in their busy practice.

Blue sky. Stunning landscape and 63 medics. The first of the 2011 UK Expedition medicine courses encompassed all of these during its four day run in March two weeks ago. It was an absolutely beautiful setting in BarrowHouse Youth Hostel overlooking Derwent Water and surrounded by enticing Lake District scenery.

With a combination of lecture based and outdoor practical sessions, the course covered an array of all possible expedition medicine topics one could want, and the team ensured each day started with the development of a very new – albeit pretty useless – lifeskill – whether this be the art of balloon racing, the speed of penguin racing or the logistics of passing the hand squeeze……!

Expedition Medicine had the wonderful Chris Imray (of Extreme Everest fame) joining the faculty for three of the days , imparting artfully his knowledge and immense skill base in cold weather medicine – be it altitude, frostbite, blood gases on top of Everest or HAPE. As one of the participants summarised perfectly in his feedback form when asked to list his three favourite lectures of the course …’’anything involving Chris Imray’’ ……

The four days aimed to have a balance of both the academic nature of expedition medicine – be it diving physiology, tropical medicine, legal aspects, heat – and the practicalities of expedition medicine – be it lateral thinking , communication skills, rope skills, improvised stretchers, pre- hospital wilderness resuscitation, radio use, voice procedure, extricating a casualty from a vehicle or search and rescue techniques – which it seemed to achieve successfully aided by a wonderfully diverse and experienced faculty. Plus some great socialising and networking over a beer in the shadowed hills of the Lakes.

So a great course, one we hope was inspiring , and the start for many of a journey into a fantastically challenging, diverse and thoroughly exciting world of expedition medicine…..

With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills – you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.

As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas.

Medical Director at Expedition and Wilderness Medicine and Pre Hospital Care Registrar with Kent HEMS talks about the benefits and opportunities in pursuing a line of training with the sub medical speciality of Expedition Medicine.

Chris has been the medical consultant and location medic for more than 12 documentary series including BBC’s Tribe, Amazon and Human Planet. He has also presented several documentaries about humanitarianism, science and remote indigenous societies.

Filming with remote populations in Congo, Peru and Russia lead to humanitarian work. Chris is a Patron of the medical aid agency Merlin and is also on their Emergency Response Team. He has worked as a Medical Coordinator in emergencies in Burma, Central African Republic and Pakistan.

After many years of climbing Chris was part of the team on the 2008 Caudwell Xtreme Everest Research expedition to Cho Oyu. A trip to Uganda to study worms in Chimpanzees lead to his current interest at UCL in primate viruses.

In the second article in the series, Dave Marshall gives an overview of managing pelvic fractures pre-hospitally and in an expedition environment, and introduces the use of the pelvic splint.

Edited by Dr Amy Hughes.

Pre hospital and Expedition management of pelvic trauma and use of the pelvic splint

Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Pelvic Sam Splint is essential.

Mechanism of Injury

Pelvic fractures often result in extensive disruption of the bony structures and associated ligaments of the pelvis and are potentially life-threatening injuries. The fractures associated with the greatest morbidity and mortality involve significant forces such as motor vehicle crashes, motorcyclist crash, pedestrian versus car, falls from height and crush injuries. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia, (1). It is especially important to be able to identify, treat and minimize risk of further damage when in a remote area miles from the nearest medical facility.

Understanding the mechanism of injury is vital in being able to predict the potential for significant injury to the pelvis and its underlying structures, even in the absence of clinical signs. It is, therefore, essential that time is taken to evaluate the mechanisms involved in any accident resulting from significant force or where there is pain or injury to the spine, abdomen, pelvis or femurs.

In motor vehicle accidents – a not uncommon event on expeditions – learning how to ‘read’ the wreckage to help identify possible pelvic injury, in conjunction with clinical suspicion, can significantly aid diagnoses.

The intrusion into the passenger and drivers door is likely to result in massive lateral injury to the pelvis

The intrusion into fuel tank shows the imprint of the riders pelvis. This would often result in significant fracture to the pelvis – often multiple, often ‘’open book’’ pelvis

Anatomy of the pelvis

Anatomical structure of the pelvis (2)

The pelvic ring is often likened to a polo mint in that it is almost impossible to have a significant break in one place and not another. The most common area to be damaged in trauma is the pubic rami, acetabulum and the sacroiliac joint. There is extensive vasculature through and around the pelvic ring, most notably the iliac vessels. For imagery see http://visualsunlimited.photoshelter.com/image/I0000kUOn3NJHcZU.

The greatest risk of a pelvic fracture is catastrophic haemorrhage and gentle handling of the patient in the initial and subsequent stages could literally be the difference between life and death. Whole blood clotting time is approximately 10 minutes, (depending on the environment). Expedition medics should be familiar with the ‘first clot best clot’ theory. In other words, a patient sustaining a traumatic injury resulting in haemorrhage will begin to form a clot using their own clotting factors. If this clot is disrupted they could easily bleed to death. A full fluid resuscitation will not be practical in the field as most expeditions carry a maximum of 2 litres of crystaloid. However it should be noted that overloading the patient with fluid can be equally harmful, and small boluses should be given to maintain a central pulse and cerebral perfusion. This is known as permissive hypotension and will be discussed in more detail in a future article. Disruption of this first clot in the prehospital setting could be fatal, and without access to blood and clotting agents the patient may die. Trauma will result in the patient becoming acidotic, hypothermic, and coagulopathic. (3)

This coagulopathy cannot be easily reversed pre-hospitally, each factor contributes to the decline in the others. (see above diagram). Any disruption to the first clot will have devastating consequences. Ultimately, the patient requires definitive haemorrhage control, (surgery, angiography and embolisation), and replacement of blood and clotting agents.

The glass pelvisThink of the pelvis as being made of very fragile glass, and you can see the clot in the form of a cartoon jelly inside. The jelly is very delicate and unless movement is gentle and kept to a minimum, it will ‘wobble’ to the point of destruction very easily. The same applies to the blood clot! Early recognition of the potential for a pelvic injury, gentle handling and prompt stabilisation is vital to improve the outcome of a patient injured on an expedition.

Clinical Features of a pelvic injury:(4)

Asymmetry of the pelvis – do not spring the pelvis. Visual alignment and gentle palpation of the Anterior Superior Iliac Spine may help demonstrate pelvic injury, but often the pelvis visually appears normal, thus mechanism of injury is vital in determining injury

As we have already discussed, a patient with a suspected pelvic fracture must be handled very carefully. Whether in a medical facility or the most extreme expedition environment, the same principles apply to prevent worsening the injury and preserving the clot.

Log rolling the patient should be avoided at all costs!

The medical kit available on expeditions will be minimal. Stretchers may have to be improvised and transportation limited. However, all medical kits should have some sort of pelvic binder which should be applied carefully and correctly at the earliest opportunity, (see images below).

Application of the pelvic SAM splint.

The casualty will inevitably have to be placed in the supine position, to evacuate them on whichever device is available. This can be achieved by a coordinated team approach utilising other members of the expedition.

One person should be at the head end of the patient maintaining in manual inline immobilisation, (MILS), and they will give clear commands to the team when moving the casualty, (“ready, brace, roll”). A pelvic binder such as the one shown can be applied using a minimal 10-15% roll, (enough to get a bum cheek off the ground!)

The most common problem associated with pelvic binders are incorrect positioning. Identify the greater trochanters and line up the binder. Ideally it should be applied over bare skin, though clearly this will depend on environmental factors.

Once in position the device can be tightened just enough to maintain anatomical alignment. Do not over tighten as this could cause significant further damage!

Log rolling patients, whilst sometimes useful in a controlled hospital environment following appropriate imaging, should be avoided in the pre hospital field. In simple risk versus benefit terms it could have catastrophic consequences. By using the hands available and correctly briefing the team about the amount of movement required (one cheek off!), it should be possible to optimise the care of the casualty prior to evacuating them to definitive care.

Improvised methods of pelvic splinting on expeditions

Much of the challenge of expedition medicine is improvisation. The medical kit you take out with you may not have SAM splints in them. Providing a support can be placed across the greater trochanter, then any sort of material could be used – for example clothing, a sheet, or a canvass of some kind.

Fluids

The approach to fluid management in trauma has changed. Two litres of fluid is not necessarily required for management of pelvic injury. Titrate fluid according to the presence of pulses or cerebration (alertness). The presence of a radial pulse, and even in certain circumstances (without associated head injury) presence of a femoral pulse signifies the blood pressure is sufficient to perfuse the necessary organs and promote clot preservation. Further details of permissive hypotension will follow in another article.

Analgesia

Essential – this depends on what is available. Intravenous opiates or a fentanyl lolly is ideal for analgesia, after the use of paracetamol or a NSAID.

Other injuries

Pelvic injuries are often present in conjunction with other significant injuries – spinal, femur, urological or abdominal as examples. Whether or not other injuries have been excluded, spinal precautions are essential in conjunction with good management of the pelvis.

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